Liver Transplantation for Severe Alcoholic Hepatitis: Where Are We Now?

Abstract

SEE ARTICLE ON PAGE 1357 Although a minority of patients with alcoholic liver disease (ALD) meet the rigorous criteria for acceptance, liver transplantation (LT) activity for ALD has continued to increase.1 Timing of LT for ALD differs among transplant programs, although the selection process is frequently based on the 6‐month sobriety period prior to listing.2 For severe alcoholic hepatitis (SAH) patients not responsive to medical therapy, a strict application of a period of sobriety as a policy for transplant eligibility remains controversial because most patients will have died prior to the end of the 6‐month sobriety period. Over the last decade, a gradual shift in attitudes toward LT for patients with ALD has occurred. For example, expert guidelines no longer recommend a fixed period of abstinence prior to LT3 and no longer suggest that alcoholic hepatitis is an absolute contraindication3 to LT contrary to earlier recommendations.5 There is little doubt that these changes in clinical guidelines have been partly influenced by the results of the first pilot study evaluating early LT in highly selected patients with SAH failing to respond to medical therapy.6 It demonstrated major improvement in survival with LT compared with nontransplanted patients. Early LT was associated with a low rate of recidivism to alcohol use and good compliance to medical management in the absence of graft dysfunction.6 Two recent American studies provided more data supporting early LT as a rescue therapy in patients with SAH failing to respond to medical therapy and confirmed low rates of alcohol use after LT.7 In this issue of Liver Transplantation, Bangaru et al.9 analyzed current perceptions and practice patterns of early LT for SAH in the United States using a Web‐based survey sent to medical directors and transplant hepatologists. Approximately half of the centers performed transplants, whereas the other half did not. There was no difference between centers offering early LT compared with those that did not in perception of the benefit of the 6‐month sobriety period. Half of US LT centers considered the 6‐month rule an insufficient criterion in predicting alcoholic relapse. For those LT centers performing early LT, the selection process was similar to that of the initial report6: strong social support, no prior presentation of SAH, absence of severe coexisting psychiatric disorder, extensive psychosocial evaluation, and adherence to lifelong total alcohol abstinence. Early LT could become consensual only in the more or less distant future because most of the centers not performing early LT specified that they would continue not listing patients with SAH in the near future. The main reason to keep their selection process unchanged is their perception that early LT still carries a high risk of alcohol relapse. However, such fear is not supported by a recent meta‐analysis that observed a risk of alcohol relapse of approximately 15%10 in studies using similar selection criteria to the initial report.6 Analysis of the current report should be undertaken in light of another French survey that explored the evolution of the selection process of patients with SAH11 since the publication of the original study.6 The authors observed that the number of LT centers performing early LT before and after 2011 increased from 35% to 70% and that the vast majority of French LT centers did endorse early LT as a therapeutic option in highly selected patients with SAH not responding to medical therapy.11 Similar to the current report by Bangaru et al.,9 the shift in French practice patterns occurs over an era of reduction of the length of alcohol abstinence before listing. The fear that early LT may decrease organ donation is not supported by a survey showing that most potential donors were supportive or neutral with regard to this new indication.13 Only ethical principles recommending active treatment of patients without discrimination and according to best scientific knowledge should be applied in the evaluation of changes in clinical practices.14 However, because of organ shortage, the selection process of SAH patients should remain stringent in order to limit transplant availability. The use of a combination of baseline Model for End‐Stage Liver Disease score15 and Lille score at 7 days16 seems to be the most efficient approach in identifying patients with the highest risk of short‐term mortality in order to limit the number of unnecessary procedures.17 Potential conflict of interest Nothing to report.